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A catastrophic medical blunder which saw a hospital patient killed when a feeding tube was inserted into his lung has happened again in recent weeks.
Last week we reported how Jack Jolly, 88, suffered an “obliterated” right lung and died of pneumonia when a Kent and Canterbury Hospital nurse failed to properly fit a gastric tube.
It has now emerged that the same error has been repeated at the hospital and is being urgently investigated.
While not fatal, health bosses admitted the latest mistake occurred despite the introduction of new safety procedures following Mr Jolly’s death.
East Kent Hospitals NHS Trust is refusing to comment, but we can reveal the incident happened just a week before the inquest into Mr Jolly’s death was heard last Wednesday.
During the emotionally-charged hearing, nurse Jimmy Joseph broke down as he admitted making the fatal mistake that killed the much-loved grandfather in 2013.
Mr Jolly, of Oxenden Crescent, Wingham, died within three days of the blunder.
Hospital bosses have apologised “unreservedly” to Mr Jolly’s family, and made assurances that vital changes had been made to the tube insertion procedure.
Key among these was the introduction of a mandatory rule that a second nurse must check the tube’s position before any feed is begun.
But the latest incident, more than 18 months since the new procedures were introduced, involved two extra checks of the tube by separate hospital staff.
It is not known at what point the error was spotted, or whether any food had been pumped into the patient’s lung by mistake.
Trust spokesman Stella Jones said: “We will not be commenting further on this, as it is still under investigation.
“We are working with NHS England to review the national approach to this procedure.”
Jack Jolly’s family have welcomed the apology from health chiefs.
“I’m pleased the nurse has admitted the fact he made a mistake. Putting emotions to one side, everyone makes mistakes in life" - Mick Marsh, Mr Jolly’s son-in-law
Mick Marsh, Mr Jolly’s son-in-law, said the apology was “what we’ve been waiting for all along”.
He said: “I’m pleased the nurse has admitted the fact he made a mistake. Putting emotions to one side, everyone makes mistakes in life.
“Unfortunately, his mistake had fatal consequences.”
Upon learning that a similar non-fatal incident had occurred at Kent and Canterbury Hospital recently, Mr Marsh added: “We were hoping because of what happened to Jack that the coroner would issue fresh instructions on safety procedures, to stop this happening again.
“It’s disappointing he didn’t but I think he was reluctant because there’s an investigation into the latest incident ongoing.”
Mr Marsh said the family were considering bringing a legal claim, but added: “This isn’t about money. It’s about the hospital being open and honest and about the people knowing what happened.”
Assistant coroner Christopher Morris recorded a narrative verdict rather than a finding of neglect.
Giving evidence at the hearing, DI Ian Whitehead described how police and prosecutors had ruled out bringing gross negligence manslaughter charges against Mr Joseph or the health trust.
He said: “In the circumstances, Mr Joseph’s breach of duty was more likely to be regarded by any court as a mistake made in stressful circumstances rather than conduct so bad as to be regarded as criminal.”
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